Failure to Implement Care Plan Interventions for Indwelling Catheters
Penalty
Summary
The facility failed to implement care plan interventions for two residents who required indwelling urinary catheters. Both residents had documented medical conditions—one with obstructive uropathy and neuromuscular dysfunction of the bladder, and the other with neurogenic bladder and a history of urinary tract infections—that necessitated the use of indwelling catheters. Their care plans specifically included interventions to record the amount, color, and characteristics of urine, and to monitor and document urinary output. Record reviews and interviews revealed that staff did not consistently monitor or document urinary output for either resident, as required by their care plans. Documentation from CNAs and the Nurse Treatment Administration Record lacked evidence of this monitoring. Interviews with the Administrator and the Director of Nursing Services confirmed that urinary output was not documented unless there was a physician's order, despite the care plan directives. This resulted in the facility not following the established care plans for these residents.